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$� 11855 White Rock Rd . <br /> 0 Stericycli Rancho Cordova , CA 95742 Date : 1/3/2020 <br /> ( 916 ) 351-0980 <br /> a u I fm <br /> Time : 8 : 15 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK- IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator : <br /> I certify that the following information is correct, and I have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program . I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> California State Regulations, and this quantity of waste does not exceed the specified limits for the type of waste being disposed. If this waste is later found <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name : Naglee Burk Irrigation District Company Rep . Robert Mehlhaff <br /> Company Address ; 4600 S . Tracy Blvd , STE . 114 EPA ID # CAL 000 360 640 <br /> Tracy, CA 95377 Signature : j � a� r „lld <br /> Phone Number : 209 - 835 -3232 Title : Date : <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN ATTENDANT <br /> General Waste Description ( Chemical Haz . AH State / # of Conta n,a Total Waste Total Waste Disp <br /> Constituent, Ph , WTC. ) Class Waste Code S Cont. ype/Size (gal ft) ( pounds) Meth COSI <br /> Motor Oil NR L 1 SS gal $ 11 . 00 <br /> Processing Fee $ 20 . 00 <br /> Method of Pymnt: Cash Check# / 3�i� � Inv Total Paid. $ 31 . 00 <br /> Stericycle Check- In Attendants Initials : Date : 3 <br />